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4. • Etymology: Latin, feminine of
Candidus= /Clear.
• Candidal infection is known as
‘candidiasis’, ‘candidosis’ or
older name ‘moniliasis’.

5. • Mucocutaneous candidiasis is most
commonly due to C. albicans, followed by C.
tropicalis.
• Candida are unicellular yeast-like fungi that
typically reproduce by budding, a process
that entails pinching off of the mother cell.
• It has the ability to exist in both yeast and
hyphal forms (dimorphism).
• Pseudohyphae are yeast cells that have
elongated and remained attached to each
other and they have constricted the ends.

6. • Candidal species are part of the normal commensal flora
throughout the gastrointestinal tract (mouth through anus).
• The vagina also is commonly colonized by yeast (13% of
women), most commonly by C. albicans.

7. 1. Infancy: Postnatal acquisition has been
attributed to increased survival rates of
low birth weight babies in association
with an increased number of invasive
procedures.
2. Old age: more likely to be exposed to
situations that  risk of invasive
candidiasis, including Rx with broad-spectrum
antibiotics , poor self-care/oral
hygiene, denture & xerostomia.
3. Warm climate.
4. Occlusion e.g. plastic pants (babies),
nylon pantyhose (women), dental plates.
5. Immunodeficiency e.g. low levels of
immunoglobulins, infection with HIV.
6. Broad spectrum antibiotic treatment
removal of bacteria from the skin, vagina
& GIT   environmental and nutritional
competition that favors the growth of
candidal organisms.
7. Contraceptive pill or injection, or
pregnancy.
8. Chemotherapy or immunosuppressive
medications such as systemic steroids.
9. Diabetes mellitus, Cushing's syndrome
and other endocrine conditions.
10.Iron deficiency.
11.General debility e.g. cancer, malnutrition.
12.Underlying skin disease e.g. LP,
hyperhidrosis, psoriasis.

8. I. Oral candidiasis
II. Vulvovaginal candidiasis
III. Candidal Balanitis
IV. Candidal Intertrigo
V. Napkin dermatitis (nappy or diaper rash)
VI. Chronic paronychia & Onychomycosis
VII. Chronic mucocutaneous candidiasis (CMC)

10. ORAL INFECTION OFTEN PRESENTS AS
1. Pseudomembranous form/Oral thrush
2. Atrophic form )Acute & Chronic)
3. Chronic hyperplastic form
4. Median rhomboid glossitis.
5. Denture stomatitis.
6. Angular cheilitis (perlèche).

11. • Seen in children and in adults of all ages.
• Acquired from the infected maternal mucosa during
passage of the infant through the birth canal.
• Lesions become visible as pearly patches or
plaques or flecks (like curdled milk or cottage cheese) on
the mucosal surface.
• Buccal epithelium, gums, and the palate are involved with
extension to tongue, pharynx or esophagus in severe cases.
• Lesions may progress to symptomatic erosion & ulceration  burning sensation.
• The pseudomembranous lesions are easily removed. If scraped away, an
erythematous base is exposed, bleeding or even shallow ulceration.

17. • In older adults, the development of oral thrush in
the absence of a known etiology should raise the
clinician’s index of suspicion for an underlying cause
of immunosuppression, such as malignancy or
AIDS.
• With denture stomatitis, the areas of erythema may
be painful and may affect up to 65% of patients who
wear dentures.
• Occurs as plaques that are present on the
buccal, palatal, or oropharyngeal mucosa overlying
areas of mucosal erythema.

19. DIFFERENTIAL DIAGNOSIS
1. lichen planus
2. Leukoplakia
3. Chemical burns: The superficial white material burn of oral
mucosa appears thin and delicate as compared to
pseudomembranous candidiasis.
4. Gangrenous stomatitis: pseudomembrane is dirty in color &
not raised above the surface

20. • Red patch of atrophic or Erythematous raw
and painful mucosa with minimal evidence
of the white pseudo-membranous lesions
observed in thrush.
• Depapillation of tongue occurs.
• Patients after therapy with broad-spectrum
antibiotics or with chronic iron deficiency
anemia may develop atrophic candidiasis.

21. • Includes a variety of clinically recognized
conditions in which yeast invasion of the
deeper layers of the mucosa and skin occurs,
causing a proliferative response of host
tissue.
• CANDIDAL LEUKOPLAKIA is considered a
chronic form of oral candidiasis in which firm
white leathery plaques are detected.
• It usually affects smokers and is pre-malignant.
• Red patches (ERYTHROPLAKIA) as well as
white patches may indicate malignant
change.

22. • Erythematous patches of atrophic
papillae located in the central
area of the dorsum of the tongue.

23. • Presents as chronic mucosal erythema
typically beneath the site of a denture.
• Candida spp. act as an endogenous infecting
agent on tissue predisposed by chronic
trauma to microbial invasion. Yeast may
reproduce, undisturbed, in the space
between the denture and mucosa.
• Palatal petechiae, diffuse erythema or tissue
granulation or nodularity (papillary
hyperplasia).

25. • Soreness and cracks at the lateral angles of
the mouth.
• Overlap of the skin at the angles of the
mouth, which is common in edentulous
and elderly patients, contributing factors;
1. Use of orthodontic appliances
2. Drooling
3. Atopic dermatitis
4. (Occasionally) iron or vitamin deficiencies (e.g. B2).

28. • It is a common condition in women.
• Although most candidal infections occur
more frequently with advancing age,
vulvovaginitis is unusual in older women.
In the absence of estrogen stimulation, the
vaginal mucosa becomes thin and
atrophic, producing less glycogen (a
substrate on which Candida albicans
thrives).
• Candidal colonization of vaginal mucosa is
estrogen dependent and subsequently
decreases sharply after menopause.

29. • Presents with itching, soreness, and a thick creamy white
discharge.
• Curdy white flecks within the discharge.
• Erythema of vaginal mucosa and vulval skin sometimes
spreading widely in the groin to include pubic areas,
inguinal areas and thighs.
• Erythema may spread to include the perineum & groin
with satellite pustules.
• Alternatively, the vaginal mucosa may appear red and
glazed.
• Vulvovaginal candidiasis may recur just before each
menstrual cycle (CYCLIC VULVOVAGINITIS).
• Symptoms may sometimes be aggravated by sexual
intercourse.

33. • Signs and symptoms of this candidal
infection vary but may include itching,
erythema, oozing, tiny papules, pustules,
vesicles, or persistent ulcerations on the
glans penis.
• Exacerbations following intercourse are
common.

36. 1. Contact Dermatitis e.g. to rubber condoms, fragrances or medicament
2. Flexural psoriasis
3. Fixed drug eruption
4. Lichen planus
5. Lichen sclerosus
6. Penile intraepithelial neoplasia
7. Syphilis
8. Scabies

38. • Most cases occur in skin folds where
occlusion (by clothing or shoes) produces
abnormally moist conditions.
• The most common sites of involvement are
submammary, inguinal creases, intergluteal
fold and the scrotum.
• Other sites include the perineum, and anus,
in which Candida organisms normally may be
carried.

39. • Patches with marked erythema,
peeling, cracking, and maceration,
erosion with soreness and pruritic
symptoms.
• Lesions typically have an irregular
margin with surrounding satellite
papules and pustules.

47. • Web spaces of affected fingers or toes are
macerated and have the appearance of
soft white skin, which is a condition
termed EROSIO INTERDIGITALIS
BLASTOMYCETICA.
• Typically affect web space between the
third and fourth fingers.
• Especially in individuals whose hands are
frequently exposed to water.

50. • 85-90% of infants harbor C. albicans
in the intestine and feces and in most
patients, CDD is the result of
progressive colonization from oral
and gastrointestinal candidiasis.

51. FACTORS PREDISPOSING TO INFECTION:
1. Infected stools
2. Macerated moist skin
3. Local irritation of the skin by friction
4. Ammonia from bacterial breakdown of urea
5. Intestinal enzymes
6. Detergents and disinfectants

52. • Maceration of the anal mucosa and
the perianal skin often is the first
clinical manifestation.
• Usually it starts in the perianal area,
spreading to involve the perineum
and, in severe cases, the upper thighs,
lower abdomen, and lower back.

53. • The typical eruption begins with scaly
papules that merge to form well-defined,
weeping, eroded lesions with a scalloped
border.
• A collar of overhanging scales and an
erythematous base may be demonstrated.
• Satellite flaccid papules or pustules around
the primary intertriginous plaque are also
characteristic.

55. • Candida species (not always C. albicans)
can be isolated from most patients.
• Gram negative bacteria also may act as
co-pathogens.
• Disease is more common in people who
frequently submerge their hands in
water and in diabetics.

56. • The nail fold becomes erythematous, swollen, and tender, with an
occasional discharge.
• It may start in one nail fold but often spreads to several others.
• Loss of the cuticle occurs, along with nail dystrophy and onycholysis with
discoloration around the lateral nail fold.
• A white, yellow or greenish color with hyponychial fluid accumulation
may occur that results entirely from Candida, and not Pseudomonas
infection.
• Usually leads to Candida infection of the nail plate (onychomycosis). The
nail may show onycholysis and is tenderness on pressure.

61. • CMC is a rare condition characterized by progressive, persistent and
recurrent infections of the skin, nails and mucous membranes with
Candida albicans occurring in childhood (60-80% of cases).
• Rarely, it develops in adult life. This is often as a result of a thymoma and
is associated with internal diseases such as myasthenia gravis, myositis,
aplastic anemia, neutropenia and hypogammaglobulinemia.
• It may be associated with:
1. Genetic predisposition with AD inheritance or AR inheritance.
2. Endocrinopathies e.g. hypoparathyroidism, hypothyroidism, hypoadrenalism,
diabetes mellitus.
3. Immune defects i.e. malfunctioning T-lymphocytes (usually selective defect
in cell-mediated immunity), low levels of immunoglobulin. Absent delayed-type
hypersensitivity (DTH) in response to Candida.

62. PRESENTATION:
• Infants often present with recalcitrant thrush,
candidal diaper dermatitis, or both.
• More extensive scaling of skin lesions
• Nails shows paronychia and candidal
onychomycosis  markedly thickened,
fragmented, and discolored, with significant
edema and erythema of the surrounding
periungual tissue, simulating clubbing.
• Oral involvement may extend to the esophagus,
but further extension is extremely uncommon.

63. • Widespread candidiasis of the skin, especially
scalp, periorificial, trunk, hands and feet.
• Skin lesions more frequently are acral and
characterized by erythematous, crusted,
hyperkeratotic, serpiginous granulomatous
plaques.
• The scalp may be involved with similar
hyperkeratotic plaques, which can result in
scarring alopecia.
• Systemic candidiasis is rare, but cutaneous
dermatophyte infections are common.

64. 1. Familial “pure” CMC
2. Chronic localized candidiasis
(“candidal granuloma”)
3. Autoimmune
Polyendocrinopathy–Candidiasis–
Ectodermal Dystrophy Syndrome,
(APECED).
4. Late-onset CMC
5. Familial chronic nail candidiasis
6. CMC associated with keratitis
7. CMC associated with other
immunodeficiency disorders
i. Severe combined immunodeficiency
ii. DiGeorge syndrome
iii. Hyper-IgE syndrome
8. CMC associated with
predominantly non-immunologic
conditions
i. KID syndrome
ii. Multiple carboxylase deficiency
iii. Acrodermatitis enteropathica
iv. Ectodermal dysplasia–ectrodactyly–
clefting syndrome

67. I. DIRECT MICROSCOPICAL EXAMINATION:
scrapping or swab e.g. KOH  Budding
yeast &/or pseudohyphae &/or septate
hyphae.
II. FUNGAL CULTURE: On Saboraud agar, a 48-
72 hours at temperature of 370 white
colonies.
III. HISTOPATHOLOGICAL EXAMINATION OF
SKIN OR MUCOSAL BIOPSY.

69. SPECIAL STAINS FOR CANDIDIASIS:
1. Gomori methenamine silver stain
(GMS). The stain highlights the
pseudohyphal or hyphal forms
penetrating into the keratinized
epithelium. In addition, there are yeast-like
forms in the superficial stratum
corneum.
2. PAS stain can also be used to highlight
the organisms.

70. • The characteristic feature is the
presence of neutrophils in the stratum
corneum and upper layers of the
epidermis. The neutrophils may form
small collections (spongiform
postulation) which resembles impetigo
or psoriasis.
• In the epidermis irregular acanthosis,
mild spongiosis and inflammatory
changes.
• In oral lesions: ulceration of the surface
covered with a fibrinoid exudate rich in
yeast and pseudohyphae.

73. A. GENERAL MEASURES: “6”
1. Identifying and removing predisposing factors is very important in the management
of mucocutaneous candidiasis e.g. control DM, correct iron deficiency, wearing
cotton underwear and loose fitting clothing.
2. Personal hygiene & use of a non-soap cleanser or aqueous cream for washing then
completely dry the genital areas, intertriginous areas, hands.
3. Regular use of antiseptics to clean dentures.
4. Avoid wet work, or use totally waterproof gloves.
5. Apply mild steroid cream intermittently, to reduce itching and treat secondary
dermatitis affecting the vulva, glans.
6. The consumption of yogurt two to three times per week and improved oral hygiene
may also help oral candidiasis, especially if underlying predisposing factors cannot be
eliminated but have not been shown to help in candidal vulvovaginitis.

74. B. TOPICAL TREATMENT: “6”
1. Azole antifungals—Clotrimazole, miconazole or econazole cream or gel (twice
daily)/oral troche (one oral troche dissolved in mouth five times daily)/pessaries or
vaginal tablets.
2. 1% gentian violet—can be used but it is not ideal because of the superficial necrosis
of mucosa and it may produce unsightly staining.
3. Nystatin preparations– rinse or drops (7-10 days rinse, 3-4 times daily).
4. Amphotericin-B—5-10ml of oral solution is used as a rinse and then expectorated 3-4
times daily.
5. Idoquinol—it has both antifungal and antibacterial properties. When this is combined
with corticosteroid is very helpful in management of angular cheilitis.
6. Boric acid 600mg as a suppository at night may help to acidify the vagina and reduce
the presence of yeasts.

75. C. SYSTEMIC THERAPY
• If Candida albicans infection is severe, recurrent or onychomycosis, includes the
use of any one of these “3” oral antifungals:
1. Fluconazole: 150 mg single dose or once/week
2. Itraconazole: 100 to 200 mg/d for 2 Weeks or pulsed-dose regimen
3. Ketoconazole: once-daily dose of 200 mg
• CMC often needs longer-term and higher doses than is normally necessary for
candida infections (fluconazole 100-400 mg/d or itraconazole at a dose of 200-
600 mg/d until the patient improves) but standard topical medications and
attempts at immune enhancement are usually ineffective.
• Fluconazole and amphotericin B may be used intravenously for the treatment of
the resistant lesions of CMC and systemic candidiasis.

76. • Patients for whom predisposing factors such as xerostomia and
immunodeficiency cannot be eliminated may need either continuous or
repeated treatment to prevent recurrences.
• To prevent recurrences oral antifungals (itraconazole or fluconazole) may
be taken regularly and intermittently (e.g. once a month).
• CMC initial therapy followed by maintenance therapy with the same
azole for life.

78. References
• Ihab Younis, M.D. Fungal skin infections
(Presentation)
• http://dermnetnz.org
• Google images
• Bolognia 3rd ed.
• http://www.mayomedicallaboratories.com
• Oral Candidiasis by Hemam Shankar Singh
)Presentation(